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Introduction: In June 2019, The Ottawa Hospital launched the Epic EHR system, which transitioned all departments from a primarily paper-based system to an exclusively electronic system using a one-day “big bang” approach. All Emergency Physicians (EP) received online module training, personalization sessions, and at-the-elbow support during the transition. We sought to evaluate EP satisfaction with the implementation process and the system's impact on clinical practice in a tertiary care academic emergency medicine setting. Methods: Email surveys were distributed during the pre-implementation and go-live phases. Questions were developed by the research team and piloted for face validity and clarity. Surveys were sent to staff EPs, residents and fellows. Likert scales were used to evaluate agreement with statements and the modified Maslach Burnout Inventory was used to assess burnout. Pre-post groups were compared using chi-squared tests to assess for significant differences. Future surveys will be distributed in 2020 for continued implementation evaluation. Results: Response rates were 49% (78/160) in the pre and 48% (76/160) in the post period. The majority of respondents were staff (66% pre; 75% post) working 8-15 shifts/month. Prior to launch, 52% of EPs felt the pre-training modules provided sufficient preparation, however only 32% felt this way after go-live (p = 0.02). Providers did not feel there were enough personalization (21% pre vs. 24% post, p = 0.66) or hands-on sessions offered (51% pre vs. 39% post, p = 0.15) and this opinion did not change after go-live. Before Epic, EPs were most concerned with productivity/efficiency, documentation time, and lack of support/training. Although documentation was reported to be easier after go-live by 69% of EPs, reviewing documents, using standardized workups/protocols, patient monitoring/follow-up, efficiency and billing were reported by >50% of EPs to be more difficult. Overall, there was a 22% increase in feeling confident to use Epic (28% pre vs. 50% post, p < 0.01); however, only 38% of providers were satisfied with the system. Notably, 82% of EPs reported experiencing moderate or high burnout in the post implementation period. Conclusion: Despite receiving standard EHR training and support, the majority of clinicians did not feel adequately trained or confident using Epic and reported moderate to high burnout. These findings will inform optimization efforts and they represent key considerations for other EDs planning future implementations.
Two common approaches to identify subgroups of patients with bipolar disorder are clustering methodology (mixture analysis) based on the age of onset, and a birth cohort analysis. This study investigates if a birth cohort effect will influence the results of clustering on the age of onset, using a large, international database.
The database includes 4037 patients with a diagnosis of bipolar I disorder, previously collected at 36 collection sites in 23 countries. Generalized estimating equations (GEE) were used to adjust the data for country median age, and in some models, birth cohort. Model-based clustering (mixture analysis) was then performed on the age of onset data using the residuals. Clinical variables in subgroups were compared.
There was a strong birth cohort effect. Without adjusting for the birth cohort, three subgroups were found by clustering. After adjusting for the birth cohort or when considering only those born after 1959, two subgroups were found. With results of either two or three subgroups, the youngest subgroup was more likely to have a family history of mood disorders and a first episode with depressed polarity. However, without adjusting for birth cohort (three subgroups), family history and polarity of the first episode could not be distinguished between the middle and oldest subgroups.
These results using international data confirm prior findings using single country data, that there are subgroups of bipolar I disorder based on the age of onset, and that there is a birth cohort effect. Including the birth cohort adjustment altered the number and characteristics of subgroups detected when clustering by age of onset. Further investigation is needed to determine if combining both approaches will identify subgroups that are more useful for research.
BACKGROUND: Meningiomas are the most common primary benign brain tumors in adults. Given the extended life expectancy of most meningiomas, consideration of quality of life (QOL) is important when selecting the optimal management strategy. There is currently a dearth of meningioma-specific QOL tools in the literature. OBJECTIVE: In this systematic review, we analyze the prevailing themes and propose toward building a meningioma-specific QOL assessment tool. METHODS: A systematic search was conducted, and only original studies based on adult patients were considered. QOL tools used in the various studies were analyzed for identification of prevailing themes in the qualitative analysis. The quality of the studies was also assessed. RESULTS: Sixteen articles met all inclusion criteria. Fifteen different QOL assessment tools assessed social and physical functioning, psychological, and emotional well-being. Patient perceptions and support networks had a major impact on QOL scores. Surgery negatively affected social functioning in younger patients, while radiation therapy had a variable impact. Any intervention appeared to have a greater negative impact on physical functioning compared to observation. CONCLUSION: Younger patients with meningiomas appear to be more vulnerable within social and physical functioning domains. All of these findings must be interpreted with great caution due to great clinical heterogeneity, limited generalizability, and risk of bias. For meningioma patients, the ideal QOL questionnaire would present outcomes that can be easily measured, presented, and compared across studies. Existing scales can be the foundation upon which a comprehensive, standard, and simple meningioma-specific survey can be prospectively developed and validated.
Whilst preterm-born individuals have an increased risk of developing attention-deficit/hyperactivity disorder (ADHD), and are reported to have ADHD-like attention and arousal impairments, direct group comparisons are scarce.
We directly compared preterm-born adolescents (n = 186) to term-born adolescents with ADHD (n = 69), and term-born controls (n = 135), aged 11–23, on cognitive-performance, event-related potential and skin conductance level (SCL) measures associated with attention and arousal. The measures are from baseline and fast-incentive conditions of a four-choice reaction time task, previously shown to discriminate between the individuals with ADHD and controls. We aimed to establish whether preterm-born adolescents show: (a) identical cognitive-neurophysiological impairments to term-born adolescents with ADHD (b) possible additional impairments, and whether (c) the observed impairments correlate with ADHD symptom scores.
The preterm group, like the term-born ADHD group, showed increased mean reaction time (MRT) and reaction time variability (RTV) in the baseline condition, and attenuated contingent negative variation (CNV) amplitude (response preparation) in the fast-incentive condition. The preterm group, only, did not show significant within-group adjustments in P3 amplitude (attention allocation) and SCL (peripheral arousal). Dimensional analyses showed that ADHD symptoms scores correlated significantly with MRT, RTV and CNV amplitude only.
We find impairments in cognition and brain function in preterm-born adolescents that are linked to increased ADHD symptoms, as well as further impairments, in lack of malleability in neurophysiological processes. Our findings indicate that such impairments extend at least to adolescence. Future studies should extend these investigations into adulthood.
The neuropsychological origins of negative syndrome of schizophrenia remain elusive. Evidence from behavioural studies, which utilised emotion-inducing pictures to elicit motivated behaviour generally reported that that schizophrenia patients experienced similar affective experience as healthy individuals but failed to translate emotional salience to motivated behaviour, a phenomenon called emotion–behaviour decoupling. However, a few studies have examined emotion–behaviour decoupling in non-psychotic high-risk populations, who are relatively unaffected by medication effects.
In this study, we examined the nature and extent of emotion–behaviour decoupling in in three independent samples (65 schizophrenia patients v. 63 controls; 40 unaffected relatives v. 45 controls; and 32 individuals with social anhedonia v. 32 controls). We administered an experimental task to examine their affective experience and its coupling with behaviour, using emotion-inducing slides, and allowed participants to alter stimulus exposure using button-pressing to seek pleasure or avoid aversion.
Schizophrenia patients reported similar affective experiences as their controls, while their unaffected relatives and individuals with high levels of social anhedonia exhibited attenuated affective experiences, in particular in the arousal aspect. Compared with their respective control groups, all of the three groups showed emotion–behaviour decoupling.
Our findings support that both genetically and behaviourally high-risk groups exhibit emotion–behaviour decoupling. The familial association apparently supports its role as a putative trait marker for schizophrenia.
Evidence suggests that autism and schizophrenia share similarities in genetic, neuropsychological and behavioural aspects. Although both disorders are associated with theory of mind (ToM) impairments, a few studies have directly compared ToM between autism patients and schizophrenia patients. This study aimed to investigate to what extent high-functioning autism patients and schizophrenia patients share and differ in ToM performance.
Thirty high-functioning autism patients, 30 schizophrenia patients and 30 healthy individuals were recruited. Participants were matched in age, gender and estimated intelligence quotient. The verbal-based Faux Pas Task and the visual-based Yoni Task were utilised to examine first- and higher-order, affective and cognitive ToM. The task/item difficulty of two paradigms was examined using mixed model analyses of variance (ANOVAs). Multiple ANOVAs and mixed model ANOVAs were used to examine group differences in ToM.
The Faux Pas Task was more difficult than the Yoni Task. High-functioning autism patients showed more severely impaired verbal-based ToM in the Faux Pas Task, but shared similar visual-based ToM impairments in the Yoni Task with schizophrenia patients.
The findings that individuals with high-functioning autism shared similar but more severe impairments in verbal ToM than individuals with schizophrenia support the autism–schizophrenia continuum. The finding that verbal-based but not visual-based ToM was more impaired in high-functioning autism patients than schizophrenia patients could be attributable to the varied task/item difficulty between the two paradigms.
To investigate the feasibility of a national audit of epistaxis management led and delivered by a multi-region trainee collaborative using a web-based interface to capture patient data.
Six trainee collaboratives across England nominated one site each and worked together to carry out this pilot. An encrypted data capture tool was adapted and installed within the infrastructure of a university secure server. Site-lead feedback was assessed through questionnaires.
Sixty-three patients with epistaxis were admitted over a two-week period. Site leads reported an average of 5 minutes to complete questionnaires and described the tool as easy to use. Data quality was high, with little missing data. Site-lead feedback showed high satisfaction ratings for the project (mean, 4.83 out of 5).
This pilot showed that trainee collaboratives can work together to deliver an audit using an encrypted data capture tool cost-effectively, whilst maintaining the highest levels of data quality.
A series of catalytic reactions has been performed in our laboratory using olivine-type silicates (OTS) and SiC as catalysts for the conversion of carbon-containing molecules (such as acetylene, CO and methanol) to small organic molecules (C2H4, C3H3, CH3O) and also polycyclic aromatic hydrocarbons (PAHs). Experimentally, small-to-medium-sized gas-phase compounds such as PAHs, reaction intermediates and hydrocarbon compounds were detected in situ using the time-of-light mass-spectrometry technique. Solid deposition on the catalyst surface was examined by high-resolution transmission electron microscopy and thermo-gravimetric analysis techniques. Our laboratory results show that the conversion of acetylene to PAHs, the CO disproportionation reaction for producing CO2 and carbon deposition (graphitic and carbon nanostructures), and also the transformation of methanol to hydrocarbon compounds can easily be achieved with OTS as a catalyst. Furthermore, the conversion of acetylene to PAHs could also be achieved by SiC as the catalyst. It is proposed that these catalytic reactions mimic similar chemical processes in circumstellar envelopes (CSEs).
Patients with schizophrenia have intact ability to experience emotion, but empirical evidence suggests that they fail to translate emotional salience into effortful behaviour. Previous research in patients with chronic schizophrenia suggests that working memory is important in integrating emotion and behaviour. This study aimed to examine avolition and anhedonia in patients with first-episode schizophrenia and clarify the role of working memory in emotion–behaviour coupling.
We recruited 72 participants with first-episode schizophrenia and 61 healthy controls, and used a validated emotion-inducing behavioural paradigm to measure participants' affective experiences and how experienced emotion coupled with behaviour. Participants were given the opportunity to expend effort to increase or decrease their exposure to emotion-inducing photographs. Participants with schizophrenia having poor working memory were compared with those with intact working memory in their liking and emotion–behaviour coupling.
Patients with first-episode schizophrenia experienced intact ‘in-the-moment’ emotion, but their emotion was less predictive of the effort expended, compared with controls. The emotion–behaviour coupling was significantly weaker in patients with schizophrenia with poor working memory than in those with intact working memory. However, compared with controls, patients with intact working also showed substantial emotion–behaviour decoupling.
Our findings provide strong evidence for emotion–behaviour decoupling in first-episode schizophrenia. Although working memory deficits contribute to defective translation of liking into effortful behaviour, schizophrenia alone affects emotion–behaviour coupling.
Neurological soft signs (NSS) have long been considered potential endophenotypes for schizophrenia. However, few studies have investigated the heritability and familiality of NSS. The present study examined the heritability and familiality of NSS in healthy twins and patient–relative pairs.
The abridged version of the Cambridge Neurological Inventory was administered to 267 pairs of monozygotic twins, 124 pairs of dizygotic twins, and 75 pairs of patients with schizophrenia and their non-psychotic first-degree relatives.
NSS were found to have moderate but significant heritability in the healthy twin sample. Moreover, patients with schizophrenia correlated closely with their first-degree relatives on NSS.
Taken together, the findings provide evidence on the heritability and familiality of NSS in the Han Chinese population.
Dysregulation of the striatum and altered corticostriatal connectivity have been associated with psychotic disorders. Social anhedonia has been identified as a predictor for the development of schizophrenia spectrum disorders. The aim of the present study was to examine corticostriatal functional connectivity in individuals with high social anhedonia.
Twenty-one participants with high social anhedonia score and 30 with low social anhedonia score measured by the Chinese version of the Revised Social Anhedonia Scale were recruited from university undergraduates (age 17–21 years) to undergo resting-state functional MRI scans. Six subdivisions of the striatum in each hemisphere were defined as seeds. Voxel-wise functional connectivity analyses were conducted between each seed and the whole brain voxels, followed by repeated-measures ANOVA for the group effect.
Participants with high social anhedonia showed hyper-connectivity between the ventral striatum and the anterior cingulate cortex and the insula, and between the dorsal striatum and the motor cortex. Hypo-connectivity in participants with high social anhedonia was also observed between the ventral striatum and the posterior cingulate cortex. Partial correlation analyses further showed that the functional connectivity between the ventral striatum and the prefrontal cortex was associated with pleasure experience and emotional suppression.
Our findings suggest that altered corticostriatal connectivity can be found in participants with high levels of social anhedonia. Since social anhedonia has been considered a predictor for schizophrenia spectrum disorders, our results may provide novel evidence on the early changes in brain functional connectivity in at-risk individuals.
Several narrow-line Seyfert 1 galaxies (NLS1s) have now been detected in gamma rays, providing firm evidence that at least some of this class of active galactic nuclei (AGN) produce relativistic jets. The presence of jets in NLS1s is surprising, as these sources are typified by comparatively small black hole masses and near- or super-Eddington accretion rates. This challenges the current understanding of the conditions necessary for jet production. Comparing the properties of the jets in NLS1s with those in more familiar jetted systems is thus essential to improve jet production models. We present early results from our campaign to monitor the kinematics and polarization of the parsec-scale jets in a sample of 15 NLS1s through multifrequency observations with the Very Long Baseline Array. These observations are complemented by fast-cadence 15 GHz monitoring with the Owens Valley Radio Observatory 40 m telescope and optical spectroscopic monitoring with with the 2 m class telescope at the Guillermo Haro Astrophysics Observatory in Cananea, Mexico.
We present a high resolution polarimetry and variability study of the M87 jet using VLA and HST data taken during 2002 to 2008. Both data-sets have an angular resolution as high as 0.06”, which is 2-3 times better than previous observations. New morphological details are revealed in both the optical and radio, which can help to reveal the energetic and magnetic field structure of the jet. By comparing the data with previously published HST and VLA observations, we show that the jet's morphology in total and polarized light is changing significantly on timescales of ~1 decade. We compare the evolution of the inner jet (particularly the nucleus and knot HST-1), when our observations overlap with the multi-wavelength monitoring campaigns conducted with HST and Chandra. We use these data to comment on particle acceleration and main emission processes.
Theoretical and observational work show that jets from AGN can trigger star formation. However, in the Milky Way the first -and so far- only clear case of relativistic jets inducing star formation has been found in the surroundings of the microquasar GRS 1915+105. Here we summarize the multiwavelength observations of two compact star formation IRAS sources axisymmetrically located and aligned with the position angle of the sub-arcsec relativistic jets from the stellar black hole binary GRS 1915+105 (Mirabel & Rodríguez 1994). The observations of these two star forming regions at centimeter (Mirabel & Rodríguez 1998), millimeter and infrared (Chaty et al. 2001) wavelengths had suggested -despite the large uncertainties in the distances a decade ago- that the jets from GRS 1915+105 are triggering along the radio jet axis the formation of massive stars in a radio lobe of bow shock structure. Recently, Reid et al. (2014) found that the jet source and the IRAS sources are at the same distance, enhancing the evidence for the physical association between the jets from GRS 1915+105 and star formation in the IRAS sources. We conclude that as jets from AGN, jets from microquasars can trigger the formation of massive stars, but at distances of a few tens of parsecs. Although star formation induced by microquasar jets may not be statistically significant in the Milky Way, jets from stellar black holes may have been important to trigger star formation during the re-ionization epoch of the universe (Mirabel et al. 2011). Because of the relative proximity of GRS 1915+105 and the associated star forming regions, they may serve as a nearby laboratory to gain insight into the physics of jet-trigger star formation elsewhere in the universe.
Since mid-2007 we have carried out a dedicated long-term monitoring programme at 15 GHz using the Owens Valley Radio Observatory 40 meter telescope (OVRO 40m). One of the main goals of this programme is to study the relation between the radio and gamma-ray emission in blazars and to use it as a tool to locate the site of high energy emission. Using this large sample of objects we are able to characterize the radio variability, and study the significance of correlations between the radio and gamma-ray bands. We find that the radio variability of many sources can be described using a simple power law power spectral density, and that when taking into account the red-noise characteristics of the light curves, cases with significant correlation are rare. We note that while significant correlations are found in few individual objects, radio variations are most often delayed with respect to the gamma-ray variations. This suggests that the gamma-ray emission originates upstream of the radio emission. Because strong flares in most known gamma-ray-loud blazars are infrequent, longer light curves are required to settle the issue of the strength of radio-gamma cross-correlations and establish confidently possible delays between the two. For this reason continuous multiwavelength monitoring over a longer time period is essential for statistical tests of jet emission models.
We present an analysis of the parsec-scale jet structure of the quasar 4C+21.35 with a resolution of 0.1 milliarcseconds based on 63 epochs of Very Long Baseline Array observations at 43 GHz from 2007 June to 2014 May along with the Fermi LAT γ-ray light curve and multi-frequency optical photometric and polarimetric data. We find that the innermost jet of the quasar consists of a very compact core of size ~0.03 mas, as well as feature A1 located 0.16 ± 0.03 mas from the core. The distance of A1 remains fairly stable, but its position angle with respect to the core changes from -10 to +10 deg. We detect 4 superluminal knots in the inner jet with apparent speeds ranging from 10c to 20c. The first two components appeared in the jet during the high γ-ray state of the quasar from mid-2010 to early 2011, while the fourth knot appears to be connected with the γ-ray active state in late 2013 - early 2014. The first knot can be associated with the dramatic VHE flare in 2010 June and possesses an extreme Doppler factor ~60. We find that maxima in the γ-ray light curve coincide with epochs of interaction between the moving knots and the core and feature A1. This suggests that the core and A1 are recollimation shocks where γ-ray flares occur. The Chandra 0.5-6 keV image reveals the existence of X-ray emission in the kiloparsec scale jet of the quasar that can be explained via inverse Compton scattering off the cosmic microwave background by relativistic electrons if no deceleration occurs between the parsec- and kiloparsec-scale jets.
The nearby radio galaxy M87 offers a unique opportunity for exploring the connection between γ-ray production and jet formation at an unprecedented linear resolution. However, the origin and location of the γ-rays in this source is still elusive. Based on previous radio/TeV correlation events, the unresolved jet base (radio core) and the peculiar knot HST-1 at >120 pc from the nucleus are proposed as candidate site(s) of γ-ray production. Here we report our intensive, high-resolution radio monitoring observations of the M87 jet with the VLBI Exploration of Radio Astrometry (VERA) and the European VLBI Network (EVN) from February 2011 to October 2012. During this period, an elevated level of the M87 flux is reported at TeV with VERITAS. We detected a remarkable flux increase in the radio core with VERA at 22/43 GHz coincident with the VHE activity. Meanwhile, HST-1 remained quiescent in terms of its flux density and structure at radio. These results strongly suggest that the TeV γ-ray activity in 2012 originates in the jet base within 0.03 pc (projected) from the central supermassive black hole.